Med Students Learn to Take Patients' "Spiritual History"

Moving stories of Yale medical students as they learn to ask their patients about their spiritual needs.

On Election Day, Lu Anne Dinglasan and Alex Diaz de Villalvilla joined in their fellow medical students gathering near the lobby of Yale New Haven Hospital. About 20 students dressed in short white coats paired off with mentors like Dr. Auguste Fortin to practice interviewing patients.

Fortin, whose thin, braided ponytail hangs midway down the back of his long white coat, greets Dinglasan and Villalvilla with a hug. He directs them to the elevator, which they ride to the ninth floor to meet the patients who have agreed to be part of their learning process.

Fortin's second-year Yale University medical school students are learning how to ask about their patients' spiritual lives as part of understanding the bigger picture of what brings people to the hospital.

"You're going to be asking some pretty personal questions in a minute, and what gives you the permission to do that is to connect with the patient on their terms," Fortin says quietly as health-care professionals whisk past the corner where he's giving the students a pep talk.

Villalvilla, 25, holds a packet of pages that outline important areas to cover when asking patients about their histories: from the impersonal, such as occupational exposure to chemicals and seat-belt use, to the emotional, such as spirituality and sexuality.

Though sexuality may not be the easiest thing to talk about, Fortin says, "I usually start with: `Who's at home with you?'

"If you say it in the same way as, `What do you do for work? Tell me about your schooling,' your sense of professional, respectful curiosity then translates into their willingness to take the question. If we do too much coughing and stammering and our voice trails off, the patient gets the idea that this is something embarrassing or shameful."

Dinglasan, 23, who has never asked real patients about their social background issues, looks up from her papers and asks, "Is there any certain order to these things?"

Fortin assures her that though there might not be a need to cover all the questions or ask them in a certain order, they are all important questions. "I would encourage you to ask most of these, particularly if there are some that you really dread asking about," he says.

"My suggestion would be not to start with sexuality, not to start with spirituality, not to start with illicit drugs."

Spirituality, for some people, is as sensitive a topic as sexuality, domestic violence and alcoholism. And it may be as important for doctors to find out about.

Fortin says that despite their sensitivity, patients want health-care providers to ask about these issues, but knowing how and what is appropriate to ask is a skill that needs to be taught in the medical school curriculum.

Back to the books Getting at the reason a person comes to the hospital is the primary objective of any health-care professional. But pinpointing a disease or a physical ailment shouldn't be the only thing a doctor looks for, according to Dr. Robert Smith.

Smith, a professor of medicine and psychiatry at Michigan State University, developed the interview method that Fortin teaches his students: the Integrated Patient-Centered, Doctor-Centered Interview. With a 1990 grant from the Fetzer Institute, Smith began the project to uncover patients' psychosocial needs that aren't typically addressed.

On average, doctors interrupt patients after only 18 seconds of speaking with them, Smith said. This "doctor-centered" interview, said Smith, "means that the patient doesn't get their first thought out of their mouths."

In Smith's model, the physician begins with a "patient-centered" approach. Developing that relationship between doctor and patient is what Smith calls "the essence of medicine."

This interview model allows patients to list the issues they want to discuss. Often, patients will bring up something that a physician might not think to ask about, including spirituality.

"I might tell you that I have headaches and that my grandfather died of a brain tumor," said Smith, as an example, "Then I might say, `I wish I hadn't quit going to church.'"

This admission, Smith said, gives doctors insight into a host of other psychological and spiritual factors that could influence patients' decisions to come to the hospital. "The ideal description of any patient is derived from that bio-psychosocial perspective," said Smith.

In this case, a doctor might tell a patient to keep a close eye on his headaches and to come back in a month. "Ninety-nine percent of the time, the headache's gone. So you save the patient a thousand dollars and a lot of grief," Smith said, pointing out that a simple social history inquiry can cut down on doctors' extraneous questions and recurrent patient visits.